ULTIMATE EQUITABLE OWNER INFORMATION State Form 53271 (R3 / 6-08) / Form LB 2 Explanation and Instructions This form is to be completed by the ultimate equitable owner of the applicant. Before completing you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code 23-2-5 and the rules relating to the Act which are contained in Indiana Administrative Code 710 IAC 1-22. You may access the statutes and rules through the Division’s website: www.sos.IN.gov/securities. This properly completed form must be accompanied by: • Complete set of fingerprints on an FBI fingerprint card (FD258) • Any additional documentation needed to answer questions. • DO NOT include the instructions (pages 1-3 of this form). NOTE: The license will not be issued until all required criminal background checks have been received and reviewed by the Indiana Secretary of State, Securities Division. A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE LICENSE BEING DENIED, SUSPENDED, OR REVOKED; THE IMPOSITION OF A CIVIL PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT. If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which it relates and attach this sheet to the application. For each additional sheet you provide, sign and list the applicant’s name. Submit this properly completed form and any supporting documentation to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E – 111 Indianapolis, Indiana 46204 A. GENERAL INSTRUCTIONS 1. FILING – An Ultimate Equitable Owner Information form (State Form 53271/Form LB 2) must accompany State Form 38168/Form LB 1, the Application for License as a Loan Broker. Each individual identified as an ultimate equitable owner for the applicant on Schedule A of State Form 38168/Form LB 1, must complete State Form 53271/Form LB 2. Additionally, applicants must update the roster of ultimate equitable owners on State Form 38168/Form LB1 by filing a Schedule B, thus requiring additional copies of State Form 53271/Form LB 2. 2. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout State Form 53271/Form LB 2. 3. AMENDMENTS – The applicant must notify the Secretary of State, Securities Division as required by Indiana Code § 23-2-5-10(i) of a change in any information contained in this form by submitting amendments using State Form 53271/Form LB 2 within two business days of the change. On State Form 53271/Form LB 2, complete the license number, check the Amendment box, complete Sections 1(A), 1(I), 7, and circle or otherwise identify the items being amended. 4. Completing this Ultimate Equitable Owner Information Form (State Form 53271/Form LB 2) does not authorize the individual to engage in origination activities. Each employee conducting origination activities must be registered with the Secretary of State, Securities Division by filing an Application for Registration as a Principal Manager or as an Originator (State Form 49718/Form LB 4). State Form 53271 (R3 / 6-08) / Form LB 2 Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com A. GENERAL INSTRUCTIONS CONTINUED 5. FBI Criminal Background Check: Pursuant to Indiana Code § 23-2-5-5(k)(1) each of applicant’s ultimate equitable owners must undergo an FBI criminal background check., if the ultimate equitable owner is a non-individual, then the following rules for an FBI criminal background check apply depending on the type of entity. • Corporation – all individuals owning ten percent (10%) or more of the Corporation’s equity must undergo an FBI criminal background check. • Partnership – all partners must undergo an FBI criminal background check. • L.L.C. – all members must undergo an FBI criminal background check. If a non-individual owns ten percent (10%) or more of that Corporation’s equity, is a partner in that Partnership, or is a member of that L.L.C., then the same rules for FBI criminal background checks apply for those non-individuals. These rules apply for every level of ownership until only individuals remain. The following applies to all individuals: Complete the following steps: 1. Obtain an FBI fingerprint card (FD258) from a law enforcement agency, preferably a state police post. 2. Present a valid form of ID and get fingerprinted, making sure to avoid smudging or other means of rendering the fingerprints illegible. An illegible fingerprint will result in having to start the process over including repayment of the background check fee. 3. Mail the finished fingerprint card along with your completed application to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E-111 Indianapolis, IN 46204 BE ADVISED: Failure to submit the required complete fingerprint card issued by a law enforcement agency with the appropriate certification will delay the processing of your application. The Division will NOT issue a license or a certificate of registration without the legible fingerprint card. 6. PRINT OR TYPE: Illegible or incomplete applications will be returned. B. SECTION INSTRUCTIONS SECTION 1 – ULTIMATE EQUITABLE OWNER’S IDENTIFYING INFORMATION Complete each line. SECTION 2 – RESIDENTIAL HISTORY Starting with your current address (Section 1(K)) list all addresses where you have resided within the past ten (10) years leaving no gaps. (Attach additional sheets as necessary.) Post Office Boxes are not acceptable. Report changes as they occur. SECTION 3 – EMPLOYMENT HISTORY Provide complete employment history for the past ten (10) years leaving no gaps. All entries must include the beginning and end dates of employment. Provide the full legal name of the company, beginning with your current employer. Account for all time including full & part-time employments, self-employment, military service, and homemaking. Also include periods such as unemployment, full-time student, extended travel, etc. For the purposes of this history, include both 1099 independent contractor assignments as well as W-2 status employment. Indicate by “YES” or “NO” whether this employment was financial service-related business. (Attach additional sheets as needed.) SECTION 5 - DISCLOSURES Questions must be answered fully, and must include all actions or legal proceedings occurring in any court in any jurisdiction. If the answer to any of the questions is “YES”, provide complete details of all events or proceedings in an attachment, listing the offense, cause number, date of conviction, and the court in which the individual was convicted. Additionally for bankruptcies, submit a copy of the discharge paperwork or a statement identifying the current status of the bankruptcy. Refer to the explanation of terms section of the instructions for explanations of italicized terms. State Form 53271 (R3 / 6-08) / Form LB 2 Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com SECTION 6 – LOAN BROKER VERIFICATION This section must be completed by an authorized representative of the applicant and must include original manual signature. SECTION 7 – ULTIMATE EQUITABLE OWNER VERIFICATION By signing the verification, the ultimate equitable owner is affirming that the application is true and complete, that he/she has not been convicted of a felony within the previous five (5) years or a crime of fraud or deceit within the previous ten (10) years. If the ultimate equitable owner has been convicted of a felony within the previous five (5) years or a crime of fraud or deceit in the previous ten (10) years, this information must be disclosed by attaching additional pages listing the offense, cause number, date of conviction, and the court in which the individual was convicted. The Commissioner may deny a license based on this information. C. EXPLANATION OF TERMS – The following terms are the italicized terms used throughout State Form 53271/Form LB 2 and have the following meaning. 1. GENERAL 2. APPLICANT – The loan broker applying on or amending information on State Form 38268/Form LB 1 (including schedules) or State Form/Form LB 3. The only instance in which the applicant is an individual is in the case of a sole proprietorship. CONTROL – The power, directly or indirectly, to direct the management or policies of an entity, whether through ownership of securities, by contract, or otherwise. Any person that (1) directly or indirectly has the right to vote 10% or more of a class of a voting security or has the power to sell or direct the sale of 10% or more of a class of voting securities; (2) in the case of an LLC, Managing Member; or (3) in the case of a partnership, has the right to receive upon dissolution, or has contributed, 10% or more of the capital, is presumed to control that company. JURISDICTION – A state, the District of Columbia, the Commonwealth of Puerto Rico, any territory of the United States, or any subdivision or regulatory body thereof. ORIGINATOR – A person engaged in origination activities. ORGINATION ACTIVITIES – Communication with or assistance of a borrower or prospective borrower in the selection of loan products or terms. PERSON – An individual, a partnership, a trust, a corporation, a limited liability company, a limited liability partnership, a sole proprietorship, a joint venture, a joint stock company, or another group or entity, however organized. PRINCIPAL MANAGER – The individual responsible for the supervision and management of the employees and business affairs of the licensee at a specific office location. ULTIMATE EQUITABLE OWNER – A person who, directly or indirectly, owns or controls ten percent (10%) or more of the equity interest in a loan broker licensed or required to be licensed under Indiana Code 23-2-5, regardless of whether the person owns or controls the equity interest through one (1) or more other persons or one (1) or more proxies, powers of attorney, contracts, or other arrangements. FOR THE PURPOSE OF SECTION 5 CHARGED – Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge). ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a temporary restraining order. FELONY – A felony is an offense punishable by a sentence of at least one (1) year imprisonment and/or a fine of at least $1,000. FINANCIAL SERVICES OR FINANCIAL SERVICES-RELATED – Pertaining to securities, commodities, banking, insurance, or consumer lending (including, but not limited to; acting as or being associated with a bank or savings association, credit union, mortgage lender, or loan broker). FOREIGN FINANCIAL REGULATORY AUTHORITY – Includes (1) a financial services authority of a foreign country; (2) other governmental body empowered by a foreign government to administer or enforce its laws relating to the regulation of financial services or financial services-related activities; and (3) a foreign membership organization, a function of which is to regulate the participation of its members in financial services activities listed above. FOUND – Includes adverse final actions, including consent decrees in which the respondent has neither admitted nor denied the findings, but does not include agreements, deficiency letters, examination reports, memoranda of understanding, letters of caution, admonishments, and similar informal resolutions of matters. INVOLVED – Doing an act or omission or aiding, abetting, counseling, commanding, inducing, conspiring with or failing reasonably to supervise another in doing an act or omission. MISDEMEANOR – A misdemeanor is an offense punishable by a sentence of less than one (1) year imprisonment and/or a fine of less than $1,000. ORDER – A written directive issued pursuant to statutory authority and procedures, including orders of denial, suspension, or revocation; does not include special stipulations, undertakings or agreements relating to payments, limitations on activity or other restrictions unless they are included in an order. PROCEEDING – Includes a formal administrative or civil action initiated by a governmental agency, self-regulatory organization or a foreign financial regulatory authority; a felony criminal indictment or information (or equivalent formal charge); or a misdemeanor criminal information (or equivalent formal charge). The term does not include other civil litigation, investigations, or arrests or similar charges affected in the absence of a formal criminal indictment or information (or equivalent formal charge). State Form 53271 (R3 / 6-08) / Form LB 2 Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 ULTIMATE EQUITABLE OWNER INFORMATION State Form 53271 (R3 / 6-08) / Form LB 2 Date (MM/DD/YYYY): License Number Information (if applicable). Use additional sheets if necessary. License # Jurisdiction License # Jurisdiction License # Jurisdiction License # Jurisdiction INITIAL FORM AMENDMENT To amend, circle or identify item(s) being amended 1. ULTIMATE EQUITABLE OWNER’S IDENTIFYING INFORMATION: (A) Last Name First Name (B) Social Security Number Middle Name Suffix (C) Gender Male (D) Date of Birth (MM/DD/YYYY) (E) State/Province of Birth Female (F) Country of Birth (G) List all names(s) , other than your legal name, you have used or are using, or by which you are or were known since the age of 18. This field should include for example, nicknames, aliases, and names used before or after marriage. (Use additional sheets as necessary). Name Name Name Name (H) For amendments only: If this filing reports that an individual’s name has changed, enter the new name and attach supporting legal documentation: Last Name First Name Middle Name Suffix (I) Employer Name (Loan Broker) (J) Office of Employment Address (do not use a P.O. Box): Number & Street: City: If this address is your private residence, check this box. State/Province or Country: Zip +4/Postal Code: (K) Current Residence address (if different from employment address): Number & Street: City: State/Province or Country: Zip +4/Postal Code: (L) Telephone Numbers and e-mail address: Business Phone Cell Phone (optional) E-mail address Fax line (optional) REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53271 (R3 / 6-08) / Form LB 2 Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ___________________________ Individual’s full legal name: ________________________ 2. RESIDENTIAL HISTORY: (list residential history for previous ten (10) years, leaving NO gaps): From To Street Address City State or (MM/YYYY) (MM/YYYY) Province Zip + 4 Postal Code Country 3. EMPLOYMENT HISTORY: (list employment history for previous ten (10) years, leaving NO gaps, and indicate whether the employment is financial service-related.): From To Employer (MM/YYYY) (MM/YYYY) (company name) Position Held City State or Province Country 4. Other Business: Are you currently engaged in any other business either as a proprietor, partner, officer, director, employee, trustee, agent or otherwise? (Please exclude non-financial services-related activity that is exclusively charitable, civic, religious, or fraternal and is recognized as tax exempt.) If YES, provide the following details: the name of the other business; whether the business is financial services-related; the address of the other business; the nature of the other business; your position, title, or relationship with the other business; the start date of your relationship; the approximate number of hours per month you devote to the other business; and briefly describe your duties relating to the other business. (Attach additional sheets as needed.) YES YES or NO? NO Details: State Form 53271 (R3 / 6-08) / Form LB 2 Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ___________________________ Individual’s full legal name: ________________________ 5. DISCLOSURES: Financial Disclosure YES NO (A) Within the past ten (10) years: (1) have you filed a personal bankruptcy petition or been the subject of an involuntary bankruptcy petition? (2) based upon events that occurred while you exercised control over any organization, have any filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition? (B) Has a bonding company ever denied, paid out on, or revoked a bond for you? (C) Do you have any unsatisfied judgments or liens against you? Criminal Disclosure YES NO (D) Have you ever within the past five (5) years: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (2) been charged with any felony? (E) Based upon activities that occurred while you exercised control over it, has any organization ever within the past five (5) years: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (2) been charged with any felony? (F) (1) Within the past ten (10) years have you ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a crime involving: financial services or a financial services-related business; any fraud, false statements, or omissions; any theft or wrongful taking of property; bribery; perjury; forgery; counterfeiting; extortion; or a conspiracy to commit any of these offenses? (2) Are there pending charges against you for a crime as described in 5(F)(1)? (G) Based upon activities that occurred while you exercised control over it, has an organization ever: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a crime specified in 5(F)(1)? (2) been charged with a crime specified in 5(F)(1)? Regulatory Action Disclosure YES NO (H) Has any State or federal regulatory agency or foreign financial regulatory authority ever: (1) found you to have made a false statement or omission or been dishonest, unfair or unethical? (2) found you to have been involved in a violation of a financial services-related regulation(s) or statute(s)? (3) found you to have been a cause of a financial services-related business having its authorization to do business denied, suspended, revoked or restricted? (4) entered an order against you in connection with a financial services-related activity? (5) denied, suspended, or revoked your registration or license, disciplined you, or otherwise by order, prevented you from associating with a financial services-related business or restricted your activities? 6) barred you from association with an entity regulated by such commission, authority, agency, or officer, or from engaging in a financial services-related business? (7) issued a final order based on violations of any law or regulations that prohibit fraudulent, manipulative, or deceptive conduct? (I) Are you now the subject of any regulatory proceeding that could result in a "yes" answer to any part of 5(H)? State Form 53271 (R3 / 6-08) / Form LB 2 Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name: ___________________________ Individual’s full legal name: ________________________ Civil Judicial Disclosure YES NO (J) (1) Has any domestic or foreign court ever: (a) enjoined you in connection with any financial services-related activity? (b) found that you were involved in a violation of any financial services-related statute(s) or regulation(s)? (c) dismissed, pursuant to a settlement agreement, a financial services-related civil action brought against you by a state, federal, or foreign financial regulatory authority? (2) Are you named in any pending financial services-related civil action that could result in a "yes" answer to any part of 5(J)(1)? Customer Arbitration/Civil Litigation Disclosure YES NO (K) Have you ever been named as a respondent/defendant in a financial services-related consumer-initiated arbitration or civil litigation which: (1) is still pending; or (2) resulted in an arbitration award or civil judgment against you, regardless of amount, or that required corrective action; or (3) was settled for any amount? 6. LOAN BROKER VERIFICATION: To the best of my knowledge and belief, the person completing this form is an ultimate equitable owner at the time of approval. I have taken appropriate steps to verify the accuracy and completeness of the information contained herein and with this application. I have provided the ultimate equitable owner the opportunity to review the information contained herein and the ultimate equitable owner has approved this information and signed the verification in Section 7 of this form. Company Name Signature of authorized party Print Name and Title of authorized party Loan Broker Verification must always be completed in full with original, manual signature. 7. ULTIMATE EQUITABLE OWNER VERIFICATION: I, _____________________________________, do solemnly swear or affirm under the penalties of perjury that: A. I have not been convicted in any jurisdiction of a felony within the previous five (5) years or a crime involving fraud or deceit in the previous ten (10) years other then which is disclosed on the attached documents; and B. The information appearing in this form and the attached documents hereto is true, accurate, and complete to the best of my knowledge. Signature Title Date (MM/DD/YYYY) REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53271 (R3 / 6-08) / Form LB 2 Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com